Nursing. Assignment: Practicum Assessing Client Families (Due in Week 5) Learning Objectives Students will: Assess client families presenting for p -

Nursing.
Assignment: Practicum Assessing Client Families (Due in Week 5)
Learning Objectives
Students will:

Assess client families presenting for psychotherapy
Develop genograms for client families presenting for psychotherapy

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Nursing. Assignment: Practicum Assessing Client Families (Due in Week 5) Learning Objectives Students will: Assess client families presenting for p

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To prepare:

Select a client family that you have observed or counseled at your practicum site.
Review pages 137142 of Wheeler (2014) and the Hernandez Family Genogram video in this weeks Learning Resources.
Reflect on elements of writing a comprehensive client assessment and creating a genogram for the client you selected.

Assignment
Part 1: Comprehensive Client Family Assessment
Create a comprehensive client assessment for your selected client family that addresses (without violating HIPAA regulations) the following:

Demographic information
Presenting problem
History or present illness
Past psychiatric history
Medical history
Substance use history
Developmental history
Family psychiatric history
Psychosocial history
History of abuse and/or trauma
Review of systems
Physical assessment
Mental status exam
Differential diagnosis
Case formulation
Treatment plan

Part 2: Family Genogram
Develop a genogram for the client family you selected. The genogram should extend back at least three generations (parents, grandparents, and great grandparents).

Hernandez Family Episode 6

Hernandez Family Episode 6
Program Transcript

FEMALE SPEAKER: So last week I showed you how to make a genogram, like
this one. Now, the idea behind making a genogram is to help you draw a picture
of your family history. And then we use that to discuss the relationships and
connections among your relatives. OK? So Juan, why don’t you start off and talk
about what you came up with.

JUAN HERNANDEZ: So we’re starting with my family. My father, Hector, he’s still
alive. And he married my mother, Freda. And she passed away two years ago.
And then there’s their children, myself– I’m the oldest– and then there’s my three
sisters, Marie, Senta, and Rose.

FEMALE SPEAKER: Good. And Elena, what about your family?

ELENA HERNANDEZ: Well, here’s my father, Anthony. He met and married my
mother, Sofia. They are both still alive. They had five children. Firstborn was my
brother Daniel, then my brother Tomas, then my sisters Martina and Camila, and
there’s me, the baby.

And then I met Juan, and we started our own family. And we have two beautiful
sons that you met, one, Junior, who is eight, and Alberto, who is six.

FEMALE SPEAKER: Good. So for the last several weeks we’ve been talking a lot
about how you discipline your sons at home. And both of you mentioned how
your parents used to punish you when you were growing up. Juan, why don’t you
talk about that and point to anybody on the genogram as you mention them?

JUAN HERNANDEZ: Sure. So my dad, when he was mad at me he would send
me to get books from the encyclopedia. And he’d make me hold them out,
straight out like this, until he told me to stop. It caused so much pain in my arms,
I mean, my arms felt like they would break off.

And my mom, she did basically the same thing. Except when she was really
mad, when would make me get more books than my dad. I hated those books so
much. I never went near them on my own. To me, they only meant one thing,
misery. And now, I guess I inherited that from them.

FEMALE SPEAKER: Elena, how about you?

ELENA HERNANDEZ: Yes, misery. That’s what it was like for me, too.

2013 Laureate Education, Inc. 1

Hernandez Family Episode 6

Hernandez Family Episode 6
Additional Content Attribution

MUSIC:
Music by Clean Cuts

Original Art and Photography Provided By:
Brian Kline and Nico Danks

2013 Laureate Education, Inc. 2 137

APPENDIX 3.1

Outline of the Comprehensive
Psychiatric Database

I. Identifying data
A. Age
B. Sex/Gender preference
C. Race/Ethnicity
D. Marital status
E. Children
F. How arrived?
G. Who referred? Why?
H. Mental health providers?
I. Sources of information
J. Number of times seen in this setting

II. Client-identifi ed problem
A. What the client states he or she wants help with
B. Verbatim statement

1. Im depressed.
2. My mother brought me. I dont need help.

III. History of current illness
A. Onset, duration, or change in symptoms over time

1. Organized chronologically
2. Clients perception of changes in himself or herself over time
3. Others perception of changes in the client (e.g., spouse, employer, and friend)

B. Precipitating factors
1. Why now?

C. Baseline functioning
D. Last period of stability

IV. Psychiatric history
A. Inpatient

1. Location, dates, and lengths of stay
2. Diagnoses
3. Previous episodes of current symptoms
4. Previous episodes of other disorders not described in history of current illness
5. Legal status
6. Use of medications or other treatments, including doses, blood levels,

clinical response
7. Perception of helpfulness

B. Outpatient
1. Dates, duration, and frequency of sessions
2. Location, type, and focus of treatment or therapy
3. Perception of helpfulness

Wheeler, K. (Ed.). (2013). Psychotherapy for the advanced practice psychiatric nurse, second edition : A how-to guide for evidence-based practice.
ProQuest Ebook Central http://ebookcentral.proquest.com
Created from waldenu on 2020-09-10 18:55:19.

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138 I GETTING STARTED

V. Medical history
A. Past and current medical problems

1. Illnesses, operations, and hospitalizations, especially history of open or
closed head injury, birth trauma, seizure disorder, and encephalitis or
meningitis

B. Past and current medications
1. Dosages, blood levels, and clinical response
2. Adherence

C. Primary care physician, specialists, and phone numbers
D. Allergies (and reactions)

VI. History of substance use and abuse
A. Episodes of alcohol abuse

1. What, how much, and consequences (e.g., charges for driving under the
infl uence [DUI], other legal sequelae, and loss of relationships, jobs, and
opportunities)

2. Does the client or others think he or she has a problem?
3. Typical pattern of use
4. History of blackouts, seizures, complicated withdrawal, or delirium tremens
5. History of suicide ideation, gestures, or attempts while intoxicated or

withdrawing
6. Longest period of sobriety
7. What facilitates sobriety?
8. Previous treatments (e.g., detoxifi cation, rehabilitation, counseling, and

Alcoholics Anonymous)
B. Episodes of illicit or prescription drug abuse

1. What, amount, route of administration, and consequences (e.g., DUIs,
other legal sequelae, and loss of relationships, jobs, and opportunities)

2. Does the client or others think he or she has a problem?
3. Typical pattern of use
4. History of suicide ideation, gestures, or attempts while intoxicated or

withdrawing
5. Longest period of sobriety
6. What facilitates sobriety?
7. Previous treatments (e.g., detoxifi cation, rehabilitation, counseling, and

Narcotics Anonymous)
C. Tobacco

1. Number of cigarettes or packs per day
2. Years client has smoked
3. Cessation attempts

D. Caffeine
1. Form (coffee, cola, tea, and pills)
2. Amount consumed per day
3. Cessation attempts

E. Over-the-counter drugs or herbal medications
1. What, how much, purpose, frequency, side effects, and interactions with

prescribed medications
2. Perceptions of helpfulness or effi cacy

VII. Developmental history
A. Developmental milestones and family of origin

1. Information about mothers pregnancy and delivery
2. Were developmental milestones reached as expected?
3. Childhood temperament and important family events (e.g., death,

separation, and divorce)
Wheeler, K. (Ed.). (2013). Psychotherapy for the advanced practice psychiatric nurse, second edition : A how-to guide for evidence-based practice.
ProQuest Ebook Central http://ebookcentral.proquest.com
Created from waldenu on 2020-09-10 18:55:19.

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3 ASSESSMENT AND DIAGNOSIS 139

4. Information about early experiences and relationships (e.g., school experi-
ences, academic performance, delinquency, family of origin relationships,
family stability, early sexual experiences, and history of abuse or neglect)

5. Important cultural or religious infl uences
6. Values, beliefs, or framework for meaning

B. Educational history
C. Occupational and military history

1. Number and types of jobs; reasons for termination
2. Highest rank attained; conditions of discharge
3. History of disciplinary problems or combat

D. Legal history
VIII. Family history

A. Psychiatric or substance use disorders
1. Have any family members undergone psychiatric or substance abuse

treatment (inpatient or outpatient), attempted or completed a suicide, had
problems with drugs or alcohol, and behaved strangely?

2. Have any family members successfully used any psychotropic
medications for the same or similar symptoms?

3. Family attitudes toward mental illness
B. Pertinent medical disorders in blood relatives (e.g., seizure disorder or

thyroid disease)
IX. Social history

A. Current social situation
1. Living arrangements (e.g., where, with whom, for how long, how stable,

and how satisfactory or desirable)
2. Employment (e.g., where, for how long, how stable, and how satisfactory

or desirable)
3. Financial (e.g., current sources of income, how stable, and how adequate)
4. Insurance coverage

B. Breadth of clients social life
1. Is he or she a loner or involved in an intimate relationship?
2. How diffi cult is it to get into and out of relationships?

C. Past and present levels of functioning
1. Marriage, parenting, and work
2. Client strengths and strategies used to manage stress, resources, or positive

memories (draw a line and place important positive memories and events)
3. Current functional defi cits (e.g., activities of daily living, task performance,

and relationships)
X. Trauma history

A. Ten most signifi cant disturbing events in life
B. Violence

1. To self
a. What, when, where, how, why; warning signs or symptoms, triggers,

and consequences
b. How intense, specifi c, and controllable is current ideation

2. To others or property
a. What, when, where, how, why; warning signs or symptoms, triggers,

and consequences
b. How intense, specifi c, and controllable is current ideation

3. Current access to weapons
a. What, where, why; plan for use; plan for disposition of weapon
b. How will disposition of weapons be verifi ed?

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140 I GETTING STARTED

XI. Psychiatric review of systems (ROS)
A. Includes all symptoms not part of the current episode or presentation
B. May have to ask specifi c questions about the presence or absence of these

symptoms
1. Are you now or have you ever had any of the following

C. Anxiety symptoms
1. Shortness of breath, heart palpitations, panic attacks, sweating, fl ushing,

hyperventilation, sense of doom, fear of death or collapse, cold or clammy
skin, and tingling sensations in extremities

D. Mood symptoms
1. Sadness, irritability, anergia, fatigue, lethargy, tearfulness, increased or

decreased appetite or energy, changes in sleep or libido, suicide ideation,
homicide ideation, hypomania (e.g., spending sprees, increased energy,
and religious preoccupation beyond baseline), and feelings of hopeless-
ness, helplessness, or worthlessness

E. Psychotic or cognitive symptoms
1. Hallucinations, delusions, thought insertion, thought blocking, thought

broadcasting, fl ight of ideas, hyper-religiosity, tangentiality, looseness of
associations, and circumstantiality

XII. Mental status examination (MSE)
A. Informal: begins immediately on contact with the client and includes an

informal assessment of the clients characteristics
1. Appearance
2. Manner of relating
3. Use of language
4. Mood and affect
5. Content of speech
6. Perceptions
7. Abstracting ability
8. Judgment
9. Insight

B. Formal: focused, structured assessment of the clients characteristics
1. Appearance: overall appearance, dress, grooming
2. Attitude: attitude toward examiner (e.g., hostile, cooperative, evasive)
3. Behavior and psychomotor activity: gait, carriage, posture, activity level
4. Speech
a. Rate, amount, tone, impairment, aphasia
5. Mood and affect

a. Mood (i.e., how the client reports feeling) in relation to affect
(i.e., emotional expression observed by the therapist)

b. Depth and range of emotional expression
6. Perception

a. Hallucinations
i. Auditory

ii. Visual
iii. Gustatory: taste (temporal lobe dysfunction?)
iv. Olfactory: smell (temporal lobe dysfunction?)
v. Tactile: Skin sensations (alcohol withdrawal and intoxication?)

vi. Kinesthetic: feeling movement when none occurs
vii. Hypnagogic: occurs while falling asleep

viii. Hypnopompic: occurs while waking up

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3 ASSESSMENT AND DIAGNOSIS 141

b. Illusions: misinterpretations of actual sensory stimuli
c. Depersonalization: feels detached and views self as unreal
d. Derealization: experiences objects and persons outside of self as unreal

7. Thought process
a. The pattern of a clients speech allows the therapist to observe the

quality of the thought process, including its fl ow, logic, and associations.
Abnormalities include the following:

i. Loose associations (LOAs)
ii. Tangentiality

iii. Circumstantiality
iv. Thought blocking (TB)
v. Thought insertion (TI)

vi. Flight of ideas (FOAs)
vii. Perseveration

viii. Echolalia
8. Content of thought

a. Delusions
i. Paranoid or persecutory

ii. Grandiose
iii. Nihilistic
iv. Somatic
v. Bizarre

b. Ideas of reference
c. Obsessions
d. Suicidal thoughts
e. Homicidal thoughts

9. Judgment
a. An assessment of social judgment involves determining whether a

client understands the consequences of his or her actions
b. Must recognize differences in cultural values when assessing

judgment
c. What would you do if you found a sealed, stamped, addressed

envelope on the sidewalk?
10. Insight

a. Must assess whether a person is aware of a problem, the cause of the
problem, and what type of help is needed to address the problem

11. Cognition
a. A formal mental status examination measures the ability of the brain to

function by assessing the following cognitive functions:
i. Consciousness: alert, confused, drowsy, somnolent, obtunded,

delirious, stuporous, and comatose
ii. Orientation: knows who he or she is, where he or she is, and what

day it is
iii. Memory: can remember what was eaten for breakfast today;

has remote memory for long-past events
iv. Recall: can recall three objects after 5 minutes
v. Registration: can name three objects immediately

vi. Attention: can spell world forward and backward
vii. Calculation: can do serial 7s or count backward from 20

viii. Language: can name items, repeat a phrase, follow simple
commands, read, write, and copy a design

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142 I GETTING STARTED

XIII. Diagnostic and Statistical Manual of Mental Disorders, fi fth edition (DSM-5)
differential diagnosis
A. On a single axis, lists the principal psychiatric, neurodevelopmental,

neurocognitive, and other disorders requiring further assessment, along
with the corresponding ICD code(s)

B. Includes so-called rule-out and/or provisional diagnoses
C. ICD-9 codes are listed before each disorder name, followed by ICD-10 codes

in parentheses
D. ICD-9 codes will be used in the United States through September 30, 2014.

IDC-10 codes will be used starting October 1, 2014.
XIV. Case formulation

A. Presents a brief summary of the client and rationalizes the diagnoses
1. Minimal identifying data, including past diagnosis
2. Abbreviated recapitulation of presenting symptoms, onset,

and course
3. Draws from all sections of the database as needed

B. Outlines the contributing factors, precipitants, and stressors
C. Summarizes the logic behind the differential diagnoses
D. Identifi es information still needed to confi rm the diagnoses

XV. Treatment plan
A. Biologic

1. Medications (e.g., name, dose, route, for what purpose, and clients level
of understanding of medication education)

2. Diagnostic tests (e.g., where, when, and who will administer)
3. Referrals for primary care

B. Psychological
1. Therapeutic modalities to be used and with what focus

a. Individual psychotherapy?
b. Group psychotherapy?
c. Family therapy?
d. Case management?

C. Social
1. Support or self-help groups
2. Mobilization of family resources
3. Vocational rehabilitation
4. Financial planning

D. Strengths
1. Overt identifi cation of client strengths, values, and beliefs to support or

draw from in implementing the identifi ed treatment plan

Data from APA (2006); Gordon and Goroll (2003); Marken, Schneiderhan, and Munro (2005);
Morrison (2008); Sadock, Sadock, and Ruiz (2009); Scully and Thornhill (2012); Shea (1998).

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